Child and adolescent deaths: a call for strengthening mortality surveillance systems
Authors: Shaza A Fadel, Agbessi Amouzou
Journal: The Lancet Global Health (2022)

Children and adolescents aged 5–19 years have increasing threats to their health and wellbeing, with stark inequities for those living in areas where they face poverty, preventable injuries, conflict, and climate change.1Patton GC Sawyer SM Santelli JS et al.Our future: a Lancet commission on adolescent health and wellbeing.Lancet. 2016; 387: 2423-2478Summary Full Text Full Text PDF PubMed Scopus (1368) Google Scholar Investing in their wellbeing has benefits that extend into their adult lives and the next generation.1Patton GC Sawyer SM Santelli JS et al.Our future: a Lancet commission on adolescent health and wellbeing.Lancet. 2016; 387: 2423-2478Summary Full Text Full Text PDF PubMed Scopus (1368) Google Scholar Deaths in this age group are the lowest when compared with the remainder of the lifespan, but reducing their mortality has not received enough attention until recent calls for a redesign of child health policies that prioritises a life-course approach in children up to adulthood.2UN Inter-agency Group for Child Mortality EstimationLevels & trends in child mortality: report 2021, estimates developed by the UN Inter-agency Group for Child Mortality Estimation.https://childmortality.org/wp-content/uploads/2021/12/UNICEF-2021-Child-Mortality-Report.pdfDate: 2021Date accessed: December 27, 2021Google Scholar, 3Strong KL Pedersen J Johansson EW et al.Patterns and trends in causes of child and adolescent mortality 2000–2016: setting the scene for child health redesign.BMJ Global Health. 2021; 6e004760Crossref PubMed Scopus (15) Google Scholar Estimates of causes of mortality are severely restricted with significant gaps in empirical data for children older than 5 years, especially at subnational levels which can assist with monitoring inequities. Despite this, the deaths of children and young adults that have been observed and counted are mostly associated with preventable causes of death.3Strong KL Pedersen J Johansson EW et al.Patterns and trends in causes of child and adolescent mortality 2000–2016: setting the scene for child health redesign.BMJ Global Health. 2021; 6e004760Crossref PubMed Scopus (15) Google Scholar, 4Fadel SA Boschi-Pinto C Yu S et al.Trends in cause-specific mortality among children aged 5–14 years from 2005 to 2016 in India, China, Brazil, and Mexico: an analysis of nationally representative mortality studies.Lancet. 2019; 393: 1119-1127Summary Full Text Full Text PDF PubMed Scopus (24) Google Scholar Before the COVID-19 pandemic, 1·48 million deaths occurred in 5–19-year-olds in 2019.2UN Inter-agency Group for Child Mortality EstimationLevels & trends in child mortality: report 2021, estimates developed by the UN Inter-agency Group for Child Mortality Estimation.https://childmortality.org/wp-content/uploads/2021/12/UNICEF-2021-Child-Mortality-Report.pdfDate: 2021Date accessed: December 27, 2021Google Scholar In The Lancet Global Health Li Liu and colleagues5Liu L Villavicencio F Yeung D et al.National, regional, and global causes of mortality in 5–19-year-olds from 2000 to 2019: a systematic analysis.Lancet Glob Health. 2022; 10: e337-e347Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar provide the latest annual age and sex-disaggregated estimated trends from 2000 to 2019 in causes of death for children and adolescents between the ages of 5 years and 19 years in 195 countries. They use data sources from countries categorised by levels of mortality and quality of national vital registration data. They use a Bayesian modelling approach to manage the uncertainty, biases, and gaps in empirical data for countries without high quality vital registration. Not surprisingly, as seen with previous estimates,3Strong KL Pedersen J Johansson EW et al.Patterns and trends in causes of child and adolescent mortality 2000–2016: setting the scene for child health redesign.BMJ Global Health. 2021; 6e004760Crossref PubMed Scopus (15) Google Scholar, 4Fadel SA Boschi-Pinto C Yu S et al.Trends in cause-specific mortality among children aged 5–14 years from 2005 to 2016 in India, China, Brazil, and Mexico: an analysis of nationally representative mortality studies.Lancet. 2019; 393: 1119-1127Summary Full Text Full Text PDF PubMed Scopus (24) Google Scholar causes of death are broad for this age group with road traffic injuries—which accounted for less than 8% of all deaths—the leading cause, followed by neoplasms, malaria, drowning, and diarrhoeal diseases. The estimates are skewed by the burden of high mortality in populous countries—such as India and Nigeria. Countries in western and central Africa continue to bear the highest burden of communicable diseases in addition to injuries and non-communicable diseases. Neoplasms are the second most common cause of death and have had the slowest reduction in associated mortality rates. However, almost 45% of childhood cancers are expected to remain undiagnosed or misdiagnosed in the near future.6Atun R Bhakta N Denburg A et al.Sustainable care for children with cancer: a Lancet Oncology Commission.Lancet Oncol. 2020; 21: e185-e224Summary Full Text Full Text PDF PubMed Scopus (79) Google Scholar The sex-specific differences in burden of injuries are more pronounced for adolescents aged 15–19 years. An important contribution is the separate analysis for countries made fragile or affected by conflict. By 2019, 35·1% of deaths of children and adolescents aged 5–19 occurred in these countries. Although most of the leading causes of death have declined, violence and conflict-related mortality has increased in the past decade for children and adolescents. The estimates provided by Liu and colleagues5Liu L Villavicencio F Yeung D et al.National, regional, and global causes of mortality in 5–19-year-olds from 2000 to 2019: a systematic analysis.Lancet Glob Health. 2022; 10: e337-e347Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar provide an important advance in methodological assessments of mortality data to support planning and timely measurement of the effectiveness of interventions to promote wellbeing and reduce premature mortality.7Tomlinson M Hunt X Daelmans B Rollins N Ross D Oberklaid F Optimising child and adolescent health and development through an integrated ecological life course approach.BMJ. 2021; 372m4784Google Scholar Yet, as with previous attempts, they faced the stark limitation of empirical cause of death data availability in many countries. Almost 84% of the world's 1·9 billion adolescents and children aged 5–19 years live in countries where causes of death are not routinely recorded completely or with high quality. Only 5% of datapoints derived from 21 of the 71 high mortality countries supported estimation of causes for 82·5% of the global deaths that occurred in those countries. Six countries of those without high quality vital registration systems had nationally representative verbal autopsy records. The scarcity of empirical data means that many countries, especially those in which acute attention is needed, are forced to depend on models from other countries. The effect of COVID-19 on mortality in children and adolescents aged 5–19 years is still not clear and was left unestimated.2UN Inter-agency Group for Child Mortality EstimationLevels & trends in child mortality: report 2021, estimates developed by the UN Inter-agency Group for Child Mortality Estimation.https://childmortality.org/wp-content/uploads/2021/12/UNICEF-2021-Child-Mortality-Report.pdfDate: 2021Date accessed: December 27, 2021Google Scholar, 5Liu L Villavicencio F Yeung D et al.National, regional, and global causes of mortality in 5–19-year-olds from 2000 to 2019: a systematic analysis.Lancet Glob Health. 2022; 10: e337-e347Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 8AbouZahr C Bratschi MW Cercone E et al.The COVID-19 pandemic: effects on civil registration of births and deaths and on availability and utility of vital events data.Am J Public Health. 2021; 111: 1123-1131Crossref PubMed Scopus (10) Google Scholar The advances in digital technology, with an unprecedented rise in surveys using mobile services, offer a unique opportunity to digitalise mortality surveillance systems to make them resilient to shocks—like pandemics—that often come with restrictions to population movements and traditional face-to-face data collections. Disease surveillance at health facilities alone means delayed action when deaths occur outside of health facilities. Liu and colleagues5Liu L Villavicencio F Yeung D et al.National, regional, and global causes of mortality in 5–19-year-olds from 2000 to 2019: a systematic analysis.Lancet Glob Health. 2022; 10: e337-e347Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar and others before them have emphasised the need to invest and strengthen empirical data collection.4Fadel SA Boschi-Pinto C Yu S et al.Trends in cause-specific mortality among children aged 5–14 years from 2005 to 2016 in India, China, Brazil, and Mexico: an analysis of nationally representative mortality studies.Lancet. 2019; 393: 1119-1127Summary Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 8AbouZahr C Bratschi MW Cercone E et al.The COVID-19 pandemic: effects on civil registration of births and deaths and on availability and utility of vital events data.Am J Public Health. 2021; 111: 1123-1131Crossref PubMed Scopus (10) Google Scholar, 9Amouzou A Kante A Macicame I Antonio A Gudo E Duce P Black RE National sample vital registration system: a sustainable platform for COVID-19 and other infectious diseases surveillance in low and middle-income countries.J Glob Health. 2020; 10020368Crossref Scopus (5) Google Scholar A few countries, such as India, China, and Bangladesh, have shown the usefulness of sample registration system approaches that use verbal autopsy to obtain representative cause specific mortality rates by age and sex. More recently, sample registration system have been initiated in Mozambique and Sierra Leone and initial results hold promise.9Amouzou A Kante A Macicame I Antonio A Gudo E Duce P Black RE National sample vital registration system: a sustainable platform for COVID-19 and other infectious diseases surveillance in low and middle-income countries.J Glob Health. 2020; 10020368Crossref Scopus (5) Google Scholar, 10Carshon-Marsh R Aimone A Ansumana R et al.Child, maternal, and adult mortality in Sierra Leone: nationally representative mortality survey 2018–20.Lancet Glob Health. 2022; 10: e114-e123Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar Such efforts must be emulated by other countries with high mortality rates, with support from the global health community, while civil registration and vital statistics systems are being strengthened.9Amouzou A Kante A Macicame I Antonio A Gudo E Duce P Black RE National sample vital registration system: a sustainable platform for COVID-19 and other infectious diseases surveillance in low and middle-income countries.J Glob Health. 2020; 10020368Crossref Scopus (5) Google Scholar We declare no competing interests. National, regional, and global causes of mortality in 5–19-year-olds from 2000 to 2019: a systematic analysisChild and adolescent survival needs focused attention. To translate the vision into actions, more investments in the health information infrastructure for cause of death and in the related life-saving interventions are needed. Full-Text PDF Open Access